Below is the letter we sent to Gloucestershire Care Services (GCS) as part of theirReview of Minor Injuries and Illness Units (MIIUs) in Gloucestershire. The public engagement period concluded on Wednesday August 31st, and a final decision on new - reduced - opening hours at local MIIUs will be made at the next board meeting of GCS (the next Board Meeting of Gloucestershire Care Services NHS Trust will be held on Tuesday 20 September 2016 at the Stroud Subscription Rooms, George Street, Stroud. The meeting will run from 1.45pm). The letter includes questions we have requested answers to under Freedom of Information, and was also sent to Gloucestershire Clinical Commissioning Group.

Re: Review of Minor Injuries and Illness Units (MIIUs) in Gloucestershire, including reduction in opening hours of Stroud MIIU

Dear Mr Jennings and Ms Hutton,

We have been troubled by the recent sporadic overnight closures of Stroud (and Cirencester) MIIU, and are not reassured by statements in the booklet that the proposed changes in opening hours are related to a “lack of available staff”, and “attendances between 11pm and 8am [being] comparatively few”. We would like to express our strong disappointment that 24 hour opening is not an option for Stroud or Cirencester. We do not believe you have public support for removing services unless you have shown how other local services will fill the gap, or at least until you have explained in detail what impact of a reduction in opening hours you expect on the emerging chaos and crisis in urgent care in Gloucestershire, and what steps have been taken to mitigate this.

As such, we would like clarity regarding the impact of these changes on other local healthcare services. The booklet states that “this review does recognise that by reducing access to MIIUs, there may be some additional minor pressure upon other parts of the urgent care system: this impact has already been discussed with the Trust’s partners”. We believe it is essential that the outcome of these discussions is public. Specifically, we ask: what have Gloucestershire Care Services and the Gloucestershire Clinical Commissioning Group done to assess the impact of changes to MIIU opening hours on Out Of Hours and urgent care services in Stroud and Gloucestershire?

We note that local Out of Hours provision is already in turmoil, with the service having been closed for 560 hours at The Dilke, and 195 hours here in Stroud in a single year, and South West Ambulance Service Foundation Trust say they “do not believe we can continue to offer this service effectively, and within the current contractual constraints, the trust does not have the resources to improve the service to a level that is satisfactory for ourselves, patients or commissioners”.[1] We further note that the relatively recent downgrading of Cheltenham A&E has predictably contributed to a worsening situation with regard to Gloucestershire Hospitals NHS Trust meeting its target to treat 95% of Accident & Emergency (A&E) patients within four hours, which has been missed every month for a year.

We believe there was a rationale for the Stroud and Cirencester service being open 24 hours in the past, or this would not be the situation prior to this review. Our position is that 24 hour opening is important to ensure universal provision that can catch occasional need and that it further provides important reassurance for the local population that care is available nearby if needed. It is clear to us that GCS itself felt 24 hour opening at Stroud was important when opening hours at the Vale Hospital were reduced in 2014, as Susan Field (then Director of Service Transformation) publicly stated at the time that this change was partly about “enabling us to keep the MIU service at Stroud General Hospital running 24 hours a day.”[2]We would appreciate further detail on attendances over this time period and ask for data on full year attendances at Stroud, Cirencester, Lydney and the Dilke as individual MIIUs annually from 2010 to 2015.

We support the sentiment behind David Miller, Chairman of Stroud Hospital League of Friends, endorsement of Option 2 in your review, which would keep Stroud and Cirencester MIIUs open for the longest possible hours with least impact on other units, but also his comment in a letter to the Stroud New and Journal: “Ideally we would like to continue opening for 24 hours but if this is unacceptable then at least until midnight.” While we have been encouraging people to sign local petitions to make clear the level or desire for 24 hour opening and support for MIIUs, we understand that this has not been included as an option for a reason. Our desire is to make clear our opposition to the erosion of NHS services locally. We note that at time of writing 2,325 people have signed Liberal Democrat County Councillor for Cirencester Cllr Joe Harris’ petition to “Keep Cirencester Hospital open overnight”, and 700 people have signed the Labour Party petition online to “Ensure 24 hour, urgent care is provided at the Minor Injuries Unit at Stroud Hospital” – with around 1,000 more signing the same petition in paper form. Regardless of the reasons and the justification for them, we see these changes in opening hours as a cuts that undermine the NHS principles of universal, comprehensive, easy to access care – and as such we wish to convey our clear opposition to them. We do not wish to endorse options which involve a reduction in opening hours, nor can we support an outcome which preserves Stroud’s MIIU at the expense of services in other parts of the county. We wish to communicate our concern that people be expected to travel greater distances, which is expensive at best and out of reach to many who are unable to drive, or to afford taxi fares. We are troubled by the way in which GCS treats increased travel distances by suggesting that because “the two sites [in the Forest of Dean] are less than 9 miles apart”, “there is sufficient capacity to handle demand in just one of the MIIUs”, particularly given the difficulties SWASFT is having in meeting Ambulance response time targets[3] and poor performance of the Non-Emergency Ambulance Service[4].

We hope our desire for the longest possible opening hours across all MIIUs is clear, despite 24 hour opening apparently no longer being possible. Nonetheless, we wish to emphasise our understanding of the importance of appropriate numbers of sufficiently qualified and competent staff. In Stroud Against the Cuts we have supported the 4:1 campaign that seeks mandatory minimum staffing ratios[5], and joined Sir Robert Francis in criticising the decision to halt work into safe staffing by the National Institute for Health and Care Excellence[6]. We appreciate that “qualified nurses and especially Emergency Nurse Practitioners are in short supply nationwide”, but would request that GCS and GCCG make public statements regarding their understanding of the causes of this shortage and policies that can either contribute to help or hinder it in future. We note that, according to the Royal College of Nursing, pay has fallen by at least 14% in real terms thanks to the government's public sector pay freeze. RCN Chief Executive, Janet Davies, says the current shortage of nurses was “a preventable crisis, caused by years of cuts to student nurse commissions and a lack of long-term workforce planning. It could be worsened by the Government’s untested gamble with student nurse funding, which our members are clear will have a negative impact on the future supply of graduate nurses”.[7]We believe that GCS and GCCG should make a clear statement that they oppose the changes to student nurse funding, and the imposition of contracts on healthcare workers outside of collective bargaining in general and specifically with regard to the current junior doctors’ contract – both policies which threaten to exacerbate staffing problems.

We would also like to know precise numbers regarding how many nurses have responded to recruitment offers by GCS in recent years, how many have been interviewed, and how many recruited?

The Gloucestershire Care Services booklet accompanying the review states that the proposals “are not about cost-cutting, as each option requires additional investment of between £210,000 and £460,000”. We would like to ask what period this additional investment applies to – is it annually or over a longer period? How does it relate to the existing budget for the MIIUs in Gloucestershire, and their budget in real terms over the past decade? Most importantly, we would like to ask about the future budget for Gloucestershire Care Services and encourage the Trust to state publicly any concerns about planned funding and demands for ‘efficiency savings’ over the next 5 years. In Stroud Against the Cuts, we fear for the future of local NHS services under the latest round of reorganisation and demand that Gloucestershire’s ‘Sustainability and Transformation Plan’ is made public as soon as possible, and GCS communicate swiftly any additional potential changes to either MIIU provision in the county or services at Stroud Hospital.

Finally, we note with disappointment that all the engagement events organised by Gloucestershire Care Services in Stroud have taken place during working hours and in the week, that they occurred with short notice, and that there was no advertising outside Trinity Church either before or indeed during the previous events. We would like to know how many people in total have attended these events as we believe it to be little more than a handful.

In summary, we would like responses to the following queries. Please treat these as Freedom of Information requests if necessary:

1. a) What has Gloucestershire Care Services done to assess the impact of changes to MIIU opening hours on Out of Hours and urgent care services in Stroud and Gloucestershire?

1. b) What has Gloucestershire Clinical Commissioning Group done to ensure a full impact assessment of changes to MIIU opening hours on Out of Hours and urgent care services in Stroud and Gloucestershire has been undertaken?

2. Please provide further details on numbers attending the county’s MIIUs from 2010 – 2015, broken down for Stroud, Cirencester, Lydney and the Dilke, by hour.

3. Please provide precise numbers regarding how many nurses have responded to recruitment offers by GCS in recent years, how many have been interviewed, and how many recruited?

4. What period does the “additional investment of between £210,000 and £460,000” cover? Is it annually or over a longer period? How does it relate to the existing budget for the MIIUs in Gloucestershire, and their budget in real terms over the past decade?

5. Please inform us of how many people in total have attended the engagement events in Stroud.

We also restate the following requests:

1. Please make public statements regarding GCS and GCCGs understanding of the causes of the MIIU staffing shortage and national policies that can either contribute to help or hinder it in future.

2. Please make a clear statement of opposition to the changes to student nurse funding, and the imposition of contracts on healthcare workers outside of collective bargaining in general and specifically with regard to the current junior doctors’ contract.

3. a) Please could you state publicly any concerns about planned funding and demands for ‘efficiency savings’ over the next 5 years?

b) Please make public Gloucestershire’s ‘Sustainability and Transformation Plan, or any aspects of it that relate to Gloucestershire Care Services.

Yours sincerely,

Stroud Against the Cuts

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